The Future of Healthcare Delivery: Balancing In-Person & Telehealth Services Post-PHE

According to a 2021 report from the Centers for Medicare & Medicaid Services (CMS), the number of telehealth services offered increased throughout the PHE, with approximately 68 million telehealth services delivered between March and October 2020. This marks a more than 2,700% increase over the same period in 2019. Virtual care adoption also increased among physicians across all specialties, with 80% having a virtual visit in 2020, up from just 22% in 2019.

Digital care offers many benefits for both patients and providers, while also facing unique challenges and limitations. On the other hand, in-person care is not a one-size-fits-all solution as well. In this article, we will explore the pros and cons and appropriate use cases for both, strategies for seamless integration, and the regulatory and reimbursement landscape for hybrid healthcare models.

Telehealth Services: Advantages and Limitations

Telehealth has the ability to improve access to treatment, save costs, increase patient participation, and provide clinicians with more flexibility. It includes a wide range of technologies, including videoconferencing, remote patient monitoring, mobile health applications, and Internet portals. The different implementation methods impose some unique challenges and limitations. Let’s take a closer look.

Benefits of Telehealth

Improved Access to Care: One of its advantages is the ability to overcome geographic barriers, which can benefit patients who live in rural or remote areas or have mobility or transportation difficulties. Additionally, virtual care can expand the availability and diversity of healthcare providers and specialists for these patients, making it easier for them to receive timely diagnosis and treatment.

Cost Savings: Telehealth can help lower healthcare costs for both patients and providers by avoiding unnecessary hospitalizations, emergency department visits, and transportation expenses. Providers can improve their efficiency and productivity by reducing overhead costs, minimizing cancellations, and optimizing scheduling and workflow. Digital care can also contribute to cost savings in the healthcare system by decreasing demand for limited resources like hospital beds and personal protective equipment (PPE).

Enhanced Patient Engagement: This technology can facilitate better communication between patients and healthcare providers by allowing for more convenient interactions and providing personalized feedback and education. Telehealth can also support patients in adhering to treatment plans by providing reminders, alerts, coaching, or support groups.

Provider Flexibility: Telehealth offers flexibility and convenience to providers by allowing them to deliver healthcare services to patients from any location, at any time. It also enables practitioners to expand their reach to new or underserved populations and collaborate with other providers across regions and disciplines.

Challenges and Limitations

Technology and Infrastructure Requirements: Telehealth requires a secure and dependable technological infrastructure that can support high-quality audiovisual communication, as well as the storage and analysis of data. Additionally, adequate broadband internet access, devices, software, technical support, and training for both patients and providers are a must.

Reimbursement and Regulatory Hurdles: Reimbursement policies for telehealth services can differ greatly among payers, states, and types of services. They may not be covered by many payers at the same rate or under the same conditions as in-person services. States as well may have different licensure requirements or practice standards for providers. Restrictions also occur on the federal level, including requirements for privacy protection (such as HIPAA), fraud prevention (such as Stark Law), or quality assurance (such as CLIA).

Patient Privacy and Data Security: Telehealth can provide significant problems to patient privacy and data security since there is a danger of unwanted access, interception, alteration, or disclosure of sensitive health information transferred or stored electronically. In addition, virtual care can create ethical and legal dilemmas related to informed consent, confidentiality, and liability.

Clinical Limitations and Quality of Care Concerns: Telehealth may not be suitable or efficient for all patients or medical conditions due to limitations in clinical assessment or concerns about the quality of care. For instance, some patients may have complex or acute medical needs that necessitate physical examination or intervention, and some medical conditions may not be readily diagnosed or monitored through telehealth methods.

In-Person Healthcare Services: Advantages and Limitations

In-person services are the traditional and most common mode of healthcare delivery and offer several advantages over telehealth services. However, in-person visits also have some limitations.

Benefits of In-Person Care

Physical Examinations and Diagnostics: In-person visits allow healthcare doctors to perform extensive and exact physical examinations and testing required for identifying, diagnosing, and treating specific illnesses or consequences. They also involve the use of specialized equipment or procedures that may not be accessible or practical through telehealth methods, including laboratory tests, imaging studies, biopsies, surgeries, or interventions.

Personal Connection and Trust: Personal contact facilitates connection and trust between patients and providers by enabling face-to-face interactions, nonverbal cues, physical touch, and emotional support. Which can lead to enhanced patient satisfaction, adherence, and outcomes by fostering rapport, empathy, compassion, and mutual understanding.

Multidisciplinary Care Coordination: They also enable providers to collaborate on multidisciplinary care for patients with complex or chronic conditions that necessitate the contribution of multiple providers or specialists from various settings or disciplines, enabling collaboration among doctors by allowing them to exchange information, and resources, or knowledge in real-time.

Challenges and Limitations

Limited Access to Specialists: It may be a significant barrier for patients living in rural or remote areas, those with mobility or transportation difficulties, or those facing other barriers to in-person care. This can result in shortages or delays in specialty care due to the uneven distribution or availability of specialists across geographic regions or practice settings. In-person care can also be costly for patients and providers, particularly for those who need to travel long distances or incur additional expenses to access specialty care.

Geographic and Socioeconomic Disparities: In-person services may exacerbate geographic and socioeconomic disparities in healthcare access and outcomes due to the unequal distribution or allocation of healthcare resources, facilities, or providers across different regions or populations. They can also create barriers or burdens for patients who have low income, lack insurance coverage, face discrimination or stigma, or have other social determinants of health that affect their ability to access or afford in-person care.

Infection Control and Patient Safety: In-person services pose significant risks of infection transmission and patient safety due to the potential exposure to pathogens or contaminants in healthcare settings or during procedures. Personal visits require strict infection control and prevention measures, such as screening, testing, isolation, sanitation, ventilation, PPE use, or vaccination to protect patients and providers from contracting or spreading infections.

Hybrid Healthcare Delivery Models: Integrating Telehealth and In-Person Care

While some services may be easily delivered via telehealth, such as medication management or mental health counseling, others may require physical contact or examination, such as surgery or wound care. Moreover, some services may benefit from a combination of both telehealth and in-person care, such as chronic disease management or post-surgery follow-up.

Primary Care and Chronic Disease Management

Primary care is the first point of contact for most patients seeking preventive or routine health services. Primary care providers (PCPs) can offer a range of services via telehealth or in-person care depending on the patient’s condition and preference.

• Telehealth to conduct initial screenings or assessments, provide health education or counseling, prescribe medications or referrals, monitor chronic conditions or symptoms, or follow up on test results or treatment plans.

• In-person care to perform physical examinations or diagnostics that require touch or observation, administer vaccinations or injections, collect specimens or samples for testing, or manage acute or complex conditions that require hands-on intervention.

Chronic disease management can also benefit from a hybrid approach that combines telehealth and in-person care to optimize patient outcomes.

• Telehealth for ongoing support and guidance, monitor vital signs or biometric data using remote devices or sensors, adjust medications or treatment plans, or provide feedback.

• In-person visits for physical examinations or diagnostics, such as blood pressure measurement or foot exam for diabetic patients, preventive services such as immunizations or screenings, or management of acute exacerbations or complications that require hands-on intervention.

Mental and Behavioral Health Services

Mental and behavioral health services include the examination, evaluation, and treatment of mental disorders and substance use disorders. These services can benefit from mixing the care delivery approaches as well.

• Telehealth for initial evaluations or assessments, psychotherapy or counseling, prescription of medications or referrals, monitoring symptoms or outcomes, or providing crisis intervention.

• In-person for neurological exams or urine drug tests, administering medications or treatments that require supervision, such as injections or detoxification, or managing severe or complex conditions that require intensive or specialized care, such as psychosis.

Urgent and Emergency Care

Urgent and emergency care necessitates prompt medical attention since it deals with problems that are significant but not life-threatening (urgent care) or possibly life-threatening (emergency care).

• Telehealth can be utilized to triage patients and establish the right level of care, diagnose and treat minor diseases or injuries, prescribe drugs or referrals, monitor vital signs or symptoms, and give follow-up care.

• In-person to perform wound care or chest X-ray, administer medications or treatments that require supervision, such as intravenous fluids or oxygen therapy, or manage severe or life-threatening conditions that require immediate intervention, such as chest pain or stroke.

Specialty and Subspecialty Consultations

• Telehealth to conduct initial consultations or second opinions, provide diagnosis and treatment recommendations, prescribe medications or referrals, monitor treatment response or outcomes, or provide follow-up care.

• In-person visits to perform biopsy or endoscopy, administer chemotherapy or dialysis, or manage severe or complex conditions that require intensive or specialized care, such as organ transplant or neurosurgery.

It is important to highlight that combining telehealth and in-person care can benefit both patients and providers. This hybrid strategy can enhance efficiency, save costs, and broaden doctors’ areas of practice, all while offering patients customized, practical, and effective care.

Strategies for Seamless Integration of Telehealth and In-Person Care

One of the challenges of implementing a hybrid healthcare delivery model is ensuring a seamless integration of telehealth and in-person care. This means the need to keep the patient’s experience and quality of care consistent and coordinated across different modes of care delivery. Let’s take a look at some of the strategies, that could ease the task:

Interoperable health information systems: Interoperability can improve the delivery of healthcare, reduce medical errors, and optimize health outcomes for individuals and communities. However, it faces challenges such as privacy, security, and standardization of health data.

Care coordination and collaboration: Care coordination and collaboration can improve patient satisfaction, reduce duplication of services, and enhance clinical outcomes. However, it can be subjected to communication gaps, role unclarity, and lack of accountability.

Patient and provider education: The provision of information and guidance to patients can increase awareness, acceptance, and satisfaction with hybrid care services. Provider education, in its turn, leads to increased competence, confidence, and compliance with telehealth standards and best practices. However, access to resources and motivation can impose a significant barrier.

Policy and reimbursement reform: The limitations in this field can be especially significant: licensure restrictions, reimbursement disparities, and legal liabilities can hinder the use of telehealth.

Regulatory and Reimbursement Landscape for Hybrid Healthcare Models

Hybrid healthcare models have the potential to offer the best of both worlds by leveraging the advantages and overcoming the limitations of each mode of service delivery. One of the most significant challenges is various regulatory and reimbursement policies that may affect the adoption, implementation, or effectiveness of the hybrid model.

State and Federal Telehealth Regulations

State and federal rules and regulations govern different areas of telehealth practice, including license, the scope of practice, requirements for care, informed consent, privacy, liability, and quality assurance. State rules and regulations may differ greatly among states or contradict federal laws and regulations, posing problems or hurdles for healthcare professionals wishing to practice beyond state lines or provide specific treatments.

Oklahoma, Pennsylvania, Rhode Island, South Carolina, Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Georgia, Idaho, Indiana, Kansas, Kentucky, Maine, Maryland, and Massachusetts are among the states that require providers to have an in-person visit with a patient before beginning telehealth services or to obtain informed consent from patients before beginning telehealth services. 

Federal laws and regulations may also impose restrictions or obligations on hybrid healthcare providers regarding privacy protection (e.g., HIPAA), fraud prevention (e.g., Stark Law), or quality assurance (e.g., CLIA). 

Some state and federal laws and regulations have been temporarily waived or modified during the COVID-19 public health emergency to facilitate hybrid healthcare expansion and access, but their long-term status and impact remain uncertain.

Read more Returning to Pre-Pandemic Licensing Requirements: Navigating Permanent and Temporary Changes

Private and Public Payor Reimbursement Policies

Healthcare providers using hybrid models of care, which involve a combination of in-person visits and telehealth services, may receive payment from private and public healthcare payors like commercial insurers, Medicare, Medicaid, or CHIP. However, reimbursement policies can vary significantly across different payors, states, and types of services, which can lead to inconsistency and uncertainty for both providers and patients. Additionally, some payors may not offer the same coverage or reimbursement rates for hybrid healthcare services as they do for in-person visits or telehealth services alone. This can be further complicated by varying eligibility requirements, billing codes, documentation requirements, and prior authorization processes across different payors.

Some payors may only reimburse for telehealth services if they are delivered through specific platforms or vendors or if they are part of a bundled payment arrangement with in-person services.

The Role of Advocacy and Stakeholder Collaboration

Hybrid healthcare models are shaped by advocacy and collaboration among different stakeholders with the goal of promoting awareness, adoption, innovation, and improvement of hybrid healthcare. These stakeholders may include patients, providers, payers, policymakers, researchers, educators, industry representatives, and professional associations. They work together to advocate for the interests and needs of hybrid healthcare through various channels and platforms such as lobbying, campaigning, education, research, innovation, and partnerships.

The American Academy of Family Physicians is a professional association that represents family physicians and advocates for hybrid healthcare policy changes at the federal and state levels. The National Consortium of Telehealth Resource Centers is a network of regional centers that provides technical assistance and resources for hybrid healthcare implementation and valuation and facilitates collaboration among various hybrid healthcare stakeholders. These efforts may contribute to shaping the regulatory and reimbursement landscape for hybrid healthcare models and enhancing their accessibility, quality, or outcomes.

Telehealth Innovation and Future Trends

Hybrid healthcare delivery models are not just a reaction to present healthcare challenges and possibilities, but also a driver of future innovation and transformation. Telehealth is continually evolving and improving as technology advances and new models of treatment emerge. The followings are some of the developments and upcoming trends that are expected to affect the hybrid healthcare landscape: 

Remote monitoring and wearable devices: Wearable gadgets and remote monitoring: Remote monitoring and wearable devices can improve patient outcomes, adherence, and engagement by delivering real-time data, feedback, and alerts.

Artificial intelligence and machine learning: Technologies that can analyze large amounts of data and provide insights, predictions, or recommendations can provide clinical decision support, diagnosis assistance, risk stratification, personalized treatment plans, or chatbot services.

Virtual and augmented reality: VR and AR can provide immersive and interactive experiences for patients and clinicians that can provide education, training, therapy, or amusement.

Direct-to-consumer telehealth: This model can enhance healthcare by providing convenience, accessibility, and affordability for patients who seek on-demand or preventive care.

Telehealth-enabled care teams can enhance healthcare services by providing multidisciplinary care, consultation, or supervision for patients who have complex or chronic conditions.